Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.
Eur J Obstet Gynecol Reprod Biol. 2021 Sep;264:276-280. doi: 10.1016/j.ejogrb.2021.07.026. Epub 2021 Jul 19.
In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.
The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.
A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%.
In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.
在前瞻性多中心 Genesis 研究中，我们为足月初产妇开发了一种剖宫产预测模型。本二次分析的目的是确定 Genesis 模型是否有可能预测与阴道分娩相关的产妇和新生儿发病率。
全国前瞻性 Genesis 试验从 7 个三级中心招募了 2336 名足月、头位、孕龄 39+0 至 40+6 周的初产妇。该预测模型使用 5 个参数评估剖宫产风险：产妇年龄、产妇身高、体重指数、胎儿头围和胎儿腹围。采用简单和多元逻辑回归分析来开发 Genesis 模型。使用该模型计算的风险评分与阴道分娩产妇的产妇和新生儿发病率相关：产后出血（PPH）、产科肛门括约肌损伤（OASI）、肩难产、1 分钟和 5 分钟 Apgar 评分≤7、新生儿重症监护（NICU）入院、头颅血肿、胎儿裂伤、神经麻痹和骨折。将与自发性阴道分娩相关的发病率与与阴道助产分娩（OVD）相关的发病率进行比较。还根据 Genesis 风险评分计算了复合发病率和与 OVD 相关的发病率的似然比。
共有 1845 名（79%）初产妇行阴道分娩。随着 Genesis 风险评分的增加，干预和发病率呈上升趋势，包括阴道助产分娩（p<0.001）、PPH（p<0.008）、NICU 入院（p<0.001）、1 分钟 Apgar 评分低（p<0.001）和 OASI（p=0.009）。与自发性阴道分娩相比，阴道助产分娩的发病率更高，包括 NICU 入院（p<0.001）、PPH（p=0.022）、分娩损伤（p<0.001）、肩难产（p=0.002）和 1 分钟 Apgar 评分<7（p<0.001）。复合结局（排除阴道助产分娩）的阳性似然比随着风险评分的增加而增加，从风险评分 5%时的 1.005 增加到风险评分>50%时的 2.507。
在最终实现阴道分娩的女性中，我们发现 Genesis 列线图确定的围产期 CD 高风险评分与更多的产妇和新生儿发病率相关。因此，Genesis 预测工具也有可能预测更严重的阴道分娩。
